Provider Demographics
NPI:1063894806
Name:TABILA, MONICA PUENTE (MA, CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:MONICA
Middle Name:PUENTE
Last Name:TABILA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21650 W 11 MILE RD STE 209
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3777
Mailing Address - Country:US
Mailing Address - Phone:248-234-1150
Mailing Address - Fax:248-659-1835
Practice Address - Street 1:1806 REIS CT
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-3330
Practice Address - Country:US
Practice Address - Phone:248-234-1150
Practice Address - Fax:248-659-1835
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-28
Last Update Date:2017-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001010235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H72109OtherBLUE CROSS BLUE SHIELD
MIMI9523Medicaid